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Anesthesia in Pulmonary Tuberculosis-Gilbert

Anesthesia in Pulmonary Tuberculosis.


R. G. B. Gilbert, M.B., B.S. (Lond.), M.R.C.S., L.R.C.P. (Lond.),
D.A., (R.C.S. and R.C.P.), Montreal, P. Q., Canada
Demonstrator, Department of Anesthesia, McGill University
Anesthetist, Herbert Keddy Memorial Hospital aizd
Associate Anesthetist, Koyal .Edward Laurentian Hospital

HIS P A P E R is in no sense original, but rather it is a report


on anesthetic methods in current use and an analysis of anesthesia conducted during the past six years by the Department
of Anaesthesia of nfcGill University at the Montreal Divisior.
of the Royal Edward Laurentian Institute.**
Introductio,n
This department has no specific routine anesthetic method for the
tuberculosis patient, but it uses various principles in selection for those
patients about to undergo thoracoplasty, pneumonectomy, lobectomy and
other types of operation.
These principles have been previously outlined and later m ~ d i f i e d . ~
Revision and increased scope have led to consideration of the following
factors :
1. The patient having either unilateral or bilateral pulmonary tuberculosis must not suffer spread of this condition. Therefore, anesthesia
which might lead to bronchial irritation, formation of tenacious sputum
or excessive respiratory effort should be avoided.
2. Unnecessary blood loss should be prevented. A bloodless field
will aid the surgeon and shorten the operation.
3. Anoxemia and circulatory collapse must be forestalled.
4. Severe paradoxical respiratory and mediastinal flap must be controlled should they arise, although these conditions are rarely seen to any
degree in thoracoplasty.
5. Metabolism must be interfered with as little as p ~ s s i b l e . ~
6. The patient should be able to cough without delay after operation
and to continue his dietary regimen with as little interference as possible.
Choice of Anesthesia
1. Thoracoplasty. The following are the techniques now most commonly adopted at this hospital :
First stage. Spinal anesthesia with 1 :1500 nupercaine5 according to
the Etherington-Wilson6 technique with modifications (see below).
Second stage. May be maintained by any one of three methods.
Presented before the Twenty-Third Annual Congress of Anesthetists, Joint Meetlng of the
Ynternational Anesthesia Research Society and the International College of hnesthe:;sts, Mon*real, Canada, October 18-21, 1948.

A 7 0 bed hospital primarily concerned with the diagnosis, investigation and surgical treati.:rnt of pulmonary tuberculosis.
219

Anesthesia and Analgesia-July-August,

1949

( a ) Intravenous injection of pentothal combined with endotracheal administration of nitrous o & l e and oxygen.
( b ) Intravenous injection of pentothal and of curare, combined
with endotracheal administration of nitrous oxide and oxygen.
(c) Endotracheal administration of cyclopropane.
Third stage. A combination of paravertebral and field block anesthesias.
2. Surgel-y of the Lungs:
Dry cases. Spinal anesthesia with 1 :1500 nupercaine and orotracheal
administration of oxygen, continuous blood transfusion and intermittent
intravenous injection of ~ r o c a i n e , ~ postoperative bronchoscopic suction.
Cases with excessive sputum. Two methods may be employed.
( a ) Endotracheal administration of cyclopropane with postural drainage
and intermittent suction, supported by continuous blood transfusion and
intermittent intravenous novocain. ('bj Intravenous injection of pentothal, and of curare, combined with administration of nitrous oxide and
oxygen and similar measures.

Technique of High Spinal Anesthesia in Presence of


Pulmonary Tuberculosis

EF'ORE O P E R A T I O N there is a consultation with the surgeons


and the risk is considered according to age, general condition,
cardiovascular stability and vital capacity.
Premedication. The treatment aims to produce a somnolent patient
with satisfactory amnesia. Divided doses of morphine up to a total of
1/2 grain and of hyoscine up to 1/75 grain are given ninety minutes to
thirty minutes before operation. The second injection of hyoscine depends upon the pulse rate following the first injection.
Anesthetic. On the patient's arrival in the operating room an intravenous drip of 5 per cent dextrose is introduced into an ankle vein and
the blood is checked for transfusion purposes. The larynx is then anesthetized with 4 per cent cocaine using a Rowbotham spray. Before perIorming the spinal tap an analeptic solution is prepared in a syringe, a
cuffed endotracheal tube is selected, tested and lubricated with 2 per cent
nupercaine in a water soluble base, and suction catheters are prepared.
The solution of nupercaine 1 :1500 is warmed, the patient helped to
a sitting posture, and the spinal injection performed with back erect. After
the prescribed period in the sitting position oxygen therapy is begun.
Nasopharyngeal administration of oxygen with a liter flow of 9 to 10
per minute is used if the patient has a vital capacity greater than 1500 cc.,
and orotracheal administration of oxygen is carried out if the vital capacity is less than 1500 cc.* The cuff is not inflated unless indicated.
The patient is then postured for the operation and it is begun. During
the operation constant observation is made, analeptics and additional seda*The modification whereby pati'ents having a vital capacity of less than 1500 cc. are given
orotracheal oxygen was suggested by Dr. C. A. MacIntosh, Surgeon-in-Chief of this Institution.
220

Anesthesia in Pulmonary Tuberculosis-Gilbert


tives are given intravenously, if and when indicated. This type of anesthesia usually results in total spinal anesthesia.
Postoperative care. This includes transfer of the patient directly
from operating table to bed. Intravenous therapy is continued if necessary and an analpetic may be given subcutaneously at this stage. Oxygen
therapy by nasal catheter is continued if indicated.
Observations During This Type of Anesthesia
of cases and records from which
the accompanying charts are compiled.
Dose of nupercaine. Originally, 16 to 17 cc. was given and the sitting
posture was maintained for fifty-five seconds. Now, 20 cc. is the average
dose, while posturing lasts for sixty to seventy-five seconds.
Use of analeptics. Unless the patient presents hypertension, analeptics are withheld before the spinal injection. Approximately 55 per cent
of cases have received analeptics during operation. The analeptic most
commonly given is pitressin-ephedrine mixture,1 10 units to 3!4 grain,
in divided doses, 1.25 units of pitressin with 3/32 grain of ephedrine intravenously, or double that amount.
The average immediate preoperative blood pressure was 127 systolic
and 76 diastolic and the average immediate preoperative pulse rate 109
per minute. The average maintained blood pressure was 87 systolic and
55 diastolic and the average maintained pulse rate 89 per minute.
Continuous blood transfusion is carried out routinely although formerly this was not the case. For a first stage thoracoplasty 1000 cc. is
given during and after the operative procedure, while for a second and
third stage patient receives 500 cc. For a pneumonectomy 1500 to 3000 cc.
is given.
Additional sedation. If sedation is not sufficient before or during
operation, demerol 50 to 100 mg. is given intravenously and this is repeated when necessary.
I n the past, pantopon was given intravenously or a sleeping dose of
pentothal was used, but small doses of demerol are less depressant and
recovery is quicker.

HESE A R E B A S E D on study

Observations Following High Spinal Anesthesia


ATIENTS A R E COMFORTABLE and quiet following operation
and they cough easily. The blood pressure has usually reached and
maintained its normal level one to three hours after leaving the operating
room. Headaches are exceptional, but temporary retention of urine is
not unknown. Severe headaches did occur, however, in nearly every
patient to whom continuous spinal anesthesia was administered. Amnesia
is the rule.
I t is hoped that the subsequent work of this D e p a r t m k t will be correlated with bronchospirometric and oxymetric findings.

221

N
N
N

++ +
+ +

Agent
1:1500 nupercahe
1:2250 nupercaine
Cyclopropane
0 2
N20
N 2 0 0;
pent.
O2 curare
N20
C3HB curare
Procaine 1%
Nupercaine .1%
Paravertebral

Technique
Etherington-Wilson
Continuous
By mask a n d
endotracheal
32
33

No.
537
9

0
1

0
1

Deaths
Corrected Absolute
4
0
0
0

Total

10

Deaths
P e r Cent
.75

CHART2
Analysis of Anesthetics Given During 1942-1947 Including All Types of Operdion

Death within 3 months=death


from any cause.
Corrected deaths=deaths to
which anesthesia a a s a contributing factor.
Absolute deaths=deaths
caused solely by anesthetic.

Remarks

Thoracoplasty
PneuSpread
Total
Deaths
CorReMonmon- Same Both Opp.
Anes.
Within rected
3 Mos. Deaths
Second Stage
Third Stage
Fourth S.atge
vision
aldi
ectomy Side Sides Side
Given
5
1 2 3 4 5
1 2 3 4
2
3
4
5
1 3 3
22
1
0
6 9 7
4 3 1
1
3
62
4
1
1
1 10 13 3
1 7 6
1
79
5
1
14 17 6
1 16 6
5
4
1
110
3
1
15 15 33
1 1 6 1
3
2
10
3
2
3
2
170
5
2
1
2
132
5
2
125 8 8
15 11 1
3
1
2
3
9
5
4
1
8
575
23
6
2 71 65 60
2 5 3 3 2 3
6
1
2
18
10
thoracoplasty, Monaldi drainage and puenmonectomy performed since 1942, carried out to show incidence of spread of disease and
majority of these were performed under high spinal anesthesia.

611
5
1
Analysis of anesthetics given during the same period including a!l types of operations, i.e. 1942-1947.

Regional

Spinal
Spinal
General

rypc

First Stage
2
3 4
Ribs
1942
6 4
1943
2 27 3
1944 '
1 30 5
1945
2 38 1
1946
2 62 5
1947
1 53
Total
8 216 18
Analysis of cases of
fatal outcome. The

W
rt.

E:

9
E:
09

IJ

L,,

Disease

c2
c4
c3

c1

M'

42
40
30

18

48
35

40

56

30

1st 4 rib R

Monaldi

1st 3 rib

1st 2 rib
2nd 2 rib

c3.5

c5

C2
c3

C3

S
S

C2.5

1st 3 rd

1st 3 rib
1st 3 rd

1st 4 rib

2nd 2 rib

1st 3 rib
1st 5 rib

3rd 2 rib

1st 3 rib L

1st 3 rib

Final
Operation
1st 3 rib

1st 3
2nd 2

Intravascular
or intrathecal

P. M. Findings or Clinical

Satisfactory

Satisfactory
Satisfactory

Satisfactory

Fall in B.P. and


pneumothorax
Satisfactory
Tuberc. empyema
Died 1 day postop.

Satisfactory

Went downhill
for 17 days
Satisfactory
Retention of
bronch. secretion
Circulatory failure

days

S
Pul. embolus 10th day
Generalized tuberc.
Gross tuberc. and
atelectasis
Toxemia and
respiratory failure
Abscess chest wall
Second. hem.
Pul. edema
Respiratory failure

S
S

S
Cerebral anemia

S
S
S

Circulatory failure

S
S

Tuberc. meningitis 2/13


Pul. embolus 2/12

2/12 later severe hemoptysis


Died 1 day postop.

Toxemia

Cause of Death
Anes.
Died 7th day postop. from
S
Tuberc. bronchopneumonia
B. P. fistula and
S
anes. shock
S
2/12 postop. developed Heart failure
pul. edema
S
Cong. H. F. developed Ril. Tuberc.
bronchopneum.
bronchopneumonia
Surgical emphysema
Died 8 days later
S
S
Circulatory failure
Operative shock
Pulmonary hemorrhage
S

Postoperative
Observations
Developed tuberc.
bronchopneum.
13. P. fistula

Tuberc.
Heart failure
pneumonia, H. F.
Brain anoxia
Brain anoxia-27
injection
S :spinal, R :regional (paravertebral)

Satisfactory
(very severe case)
Satisfactory

Satisfactory
Satisfactory
S,atisfactory
(very severe case)
Satisfactory
(very severe case)
Satisfactory
Satisfactory

Satisfactory

B1. loss and


fall in B. P.
Satisfactory
Satisfactory

Satisfactory
Statisfactory

Blood loss,
fall in B. P.
Pul. Hem. on
0. R . table
Satisfactory

Satisfactory

CoI1a p se
during op. 60'
Satisfactory

Observation
During Op.
Satisfactory

'Carried out in collaboration with Dr. Ernest Bousquet and Dr. Patrick Madore, assistant and resident surgeons of this Institntion.

1st 3 rib

1st 3 rib

3rd 2 rib

1st 3 rd
1st 3. 2nd 3 Pneumonectomy
3rd 3
1st 3 R
Revision
2nd 3
1st 3 rib
2nd 4 rib
2nd 3 rib
1st 3 rib
1.2. 3 R
L 2nd 2 rib
L. i s t 2
1st 3
Revision
2nd 4
1st 3. 2nd 4 3rd 2 rib
1st 3
2nd 2 rib

S
C1.5, C3

C5

C1

c2
c1.5

C4

Previous
Operations

C:cavity, 3:3 cm. diam., S:stationary

c3

23

F
F

32
21

C1.5
C6

c3
c3

36

c3

27

M
M

C3.6

c4
c2

44
20

19

17

21
34

c4.5

37

C4

c1.5

C2

39

45

%ge Sex
__

CHART3
Analysis of All Deaths Occurring Within Three Months of Ofieration'

Anes.

sibility

Respon-

Anesthesia and Analgesia- July-August, 1949


Summary
1. Guiding factors in selection of anesthesia in pulmonary tuberculosis are considered.
2. The choice of anesthesia a t this Institution is stated.
3. The details of the present method of high spinal anesthesia with
1 :1500 nupercaine are outlined.
4. Some observations during and after high spinal anesthesia are
presented.
5. Chart 1 shows incidence of spread of disease and postoperative
deaths.
6. Chart 2 is an analysis of 611 anesthesias given during the 19421947 period.
7. Chart 3 is an analysis of all deaths occurring within three months
of operation.
Bibliography
1. Gurd, Fraser B.,, Vineberg, A. M. and Bourne, U'esley: Our Experience in the Employment of Spinal Anesthesia for Thoracoplasty. I . Thoracic Surg., 7:5, 506-51 I (June) 1938.
2. Ibid.: Further Experiences in the Use of Spinal Anesthesia for Thoracoplaty. A m .
Surg., 110:s (Nov.) 1939.
3. Bourne, Wesley, Leigh, M. Digby, Inglis, A. Nelson and Howell, G . Rennie: Spinal
Anesthesia for Thoracic Surgery. Anes., 3:3, 2724281 ( M a y ) ,1942.
4. Bourne, Wesley: Anaesthesia for the Tuberculous Patient. BY. J . Anes.. 1 8 9 , 1942.
5 . Jones, W. Howard: Spinal Analgesia: A New Method and a New Drug, Percaine.
E r . J. Ams., 7:99-113 (April) 1930.
6. Etherington-Wilson, W.: Intrathecal Nerve Root Block. Some Contributions and a New
Technique. Anes. and Analgesia, 14:102-110 (May) 1935.
7. Beck, C. S. and Mautz, F. R.: The Control of Heart Beat by the Surgeon. Ann. Surg.,
106:525, 1937.
8. Burstein, C.: Treatment of Acute Arrhythmias during Anesthesia by Intravenous Procaine. Anes., 7:2, 113, 1946.
9. Bittrick, N. M. and Powers, W. F . : Intravenous Procaine in Thoracic Surgery. Aria.
and Analgesia 27:4 (July) 1948.
10. M'elvhle, K. I. : Combined Ephedrine-Pituitary Extract (Posterior Lobe) rherapy in
Histamine Shock. J . Pharm. and E x ) . Tlterapy., 44:239-239 (March) 1932.

Spinal Anesthesia in More Than Five Thousand Vaginal Deliveries.


W. C. Rogers. Wrsttw Joiirtzal Surg., 0 bstctrics mid Gynrcology,
5 0 2 3 6 (April) 1948.
HE CASES reviewed by Rogers include all patients delivered
vaginally from September 1943, when spinal anesthesia was first
used for deliveries, to July 1947. The total number of vaginal deliveries
occurring in this forty-six month period were 5,837, in 5,067 of which
spinal anesthesia was used and in 770 nitrous oxide. From 3 to 10 mg.
of tetracaine hydrochloride in 1.5 to 2 per cent dextrose solution is used.
This solution makes it relatively easy to control the height of the anesthetic. The average dose used is 6 mg. tetracaine, which will ordinarily
produce complete anesthesia for cne to two hours. The anesthetic is
administered with the patient lying on her left side, the head of the table
being elevated 2 or 3 inches ( 5 . 1 to 7.6 cm.) . There were no maternal
or fetal deaths and no neurologic complications. Spinal anesthesia is not
an obstetric panacea, but when judiciously used affords a safe means of
painless delivery.
~

224